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HomeMy WebLinkAbout0062 CROOKED CARTWAY - Health 52 Crooked Cartway Marstons Mills P LA 065 OQj TOWN OF BARNSTABLE p LOCATION 6d, Crooj0 ec►'/ Gq SEWAGE#,,?(//'c�3 7 �VILLJAGE I-/`fir/U ASSESSOR'S MAP&PARCEL AS 0 0 IN NAME&PHONE NO. .N-CC,/�,s/c, - sob-5'a8 Asa P SEPTC.TANK CAPACITY /000 C44L I [',C r;f ,.f LEACHING FACILITY:(type) SOOG&I, VHgq i"(Aj (size) 13 YL NO.OF BEDROOMS 3 , °m OWNER ChfA/-/t_-rs `n%s 47 'PERMIT DATE: , COMPLIANCE DATE: -7—2 f r Separation Distance Between the: :. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY i r�r s , . � G a �� f.. cf� 3 3 � , No. Zo` ^� 1 1 Fee & V THE COMMONWEALTH OF MASSACHUSETTS. Entered in co puter: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ltlYl�atlDtt,fOr Mispo8al Opstem CDn$tCUttion 3permit Application for a Permit to Construct( ) Repair vo�Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. croo ��,✓�y Owner's Name,Address,and Tel.No. �I Af. ,, Assessor's Map/Parcel 65- -3 Installer's N ,Address,and TG h1n sog_yd - Designer's Name,Address,an Tel.No. wc,e l'r cCl�t 8�?6Z, Os(cw.(k Type of Building: DwellingNo.of Bedrooms � Lot Size sq-€E: Garbage Grinder(vp Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) .3.3 O gpd Design flow provided 3� 9 gpd Plan Date 4v(`•o2S,c"16 0 3 Number of sheets Revision Date Title Size of Septic Tank /10 aoCO.1 'CFY3�� 1 nType of S.A.S. 00 60 _ Crt M Lclz 3 Description of Soil 14J QC- l91 - 0216/NiY�J R Nature of Repairs r Alterations((Answer when applicable) /j'10 t2 CX(J 0 7 !f t:2J t °✓/ t7/� SG• cJ�`-ter cy e�P}}1S�wl'�'S?'wC - aCJ5c C Ch-�i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar f Health.41 Date ��� 010 l Application Approved by Date l� Application Disapproved by Date for the following reasons Permit No. , ( '" �'3 Date Issued t/ I No. ©/ `"' Fee /� V THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Yi at%an�for Disposal 6pstem CowRturtion permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location,Address or Lot No.6 Q r 00 h P 1 �i�`%�.P}y Owner's Name,Address,and Tel.No. f7•/7,i1j L Assessor's Map/Parcel G 51_3 OC-0 S)OLi Installer's Name,Address and Tel-No. Wig•�//8- Designer's Name,Address,an Tel.No. dSr�ce � 8� Ort�St OSICr�.�� Type of Building: Dwelling No.of Bedrooms Lot Size sq.-ft. Garbage Grinder Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow(min.required) 3�O gpd Design flow provided 310-/ gpd Plan Date A,( • c i, 3d G Number of sheets Revision Date o , Title Size of Septic Tank 1,O oc G-/ x X' ��� Type of S.A.S. .,J 00 6o C'Nr)Jl-,LIZ Description of Soil H OC" Dr'a1 u o Nature of Repairs or Alterations(Answer when applicable) Anho C /b1 o) (�� a v% bi3d Sc• i IGVy- Date last inspected: , z Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f Health. , Smgne Date ��� v It Application Approved by Date Application Disapproved by Date for the following reasons Permit No. :;)c / '- 3 Date Issued -2 f 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by`S cNUv2 1,t�c (o 4l� at 6,k C,-,U R(J C A ( .�a ��(.�! has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No.c 3 I dated Installer�Vjc•�« ��c.G c` • `�`' Designer J #bedrooms Approved design flow 3d gpd The issuance of thi 'pe t shall not be construed as a guarantee that the system willDincibr�as de St. Date �I Inspector 'V "' No. 13 Fee /QC) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION— BARNSTABLE,MASSACHUSETTS Disposal bpstem Construction permit Permission is hereby granted to Constru�jt( ) Repair(� Upgrade( ) Abandon( ) System located at C.S� Cf u h o and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction muf t be 7pleted within three years of the date of this pe, it., Date /l /, Approved by, c � TOWN OF BARNSTABLE LnCATION 6� CROOOkn a/�ray SEWAGE #(�DO3r1-/a VILLAGE //AAMO IJ ZZI ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. I Aa-CC-1/71 SEPTIC TANK CAPACITY I/ooc)6�f. LEACHING FACILITY: (type) c�00r(�� A0, (size) 13(has v`Ovc^oy -a NO.OF BEDROOMS BUILDER OR WNER PERMITDATE: Sa-3-0-3 COMPLIANCE DATE: C`q" 03 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A-a - 39 3 - 39 Pr� - y7 � G3 - 33 d I Y - 4 - No. L�WJ Fee G ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYfcation for Migonl 6petem Construction permit Application for a Permit to Construct( )Repair(V')Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No., oa Cgoo Gq,-�Twr#3 Owner's Name,Address and Tel.No. J�'1/?r.Ed/anllidb CV(A-LeS CrQA) y�8^6oi0 Assessor's Map/Parcel 6s� 16o1 Crud" (ARwgj H. Kati Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.B,to s63 F1�c�1(� ►�� 'Sd.. �YlLA53o c� O to cn ,tic t„ ON �o1S°tt( Type of Building: ? Dwelling No.of Bedrooms J Lot Size�.66�t�rr sit Garbage Grinder 'KD) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 336 gallons per day. Calculated daily flow gallons. Plan Date AV S-a q-6% Number of sheets / Revision Date Title Size of Septic Tank IOo o GA . Ct 7-; Type of S.A.S. ,\7-5006�W k,7tIUc/ S Description of Soil 0 '/5i4� /DA A c%f /y E �����,1019n, 3 ° a r= s177-b,q a Y. _ �� 1Z cod,v Nature of Repairs or L�o-IrAlterations(`Answer when applicable)�i3���/.1"�✓ is-,�0 s-L Ls LA l Yt OS t ,4" Ytovt L — Ip L,3 J Q ue• _s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is-stied by this Bo d of H Signed Date le0l_- 3-03 Application Approved by _r Date 5s-3-0.3 Application Disapproved for the following reasons Permit No. 2co — ZZ y Date Issued 3 03 11 i 2 q I' No. ✓ � —1 � .` Fee , E�COMMONWEALTH OF MASSACHUSET S Entered in computer: TH ¢' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIPPlication for Mfgozal *p$tem Conotr�uction Permit Application for a Permit to Construct( )Repair(PUpgrade( )Abandon( ) . El Complete System ❑Individual Components Location Address or Lot No., ,;2 (Roo/rc.3 Car/w i) Owner's Name,Address and Tel.No. 1')/�3,e /U/uf%1�/J Ci-t,A-Lc G/0 Assessor's Map/Parcel L,Z C'roul o Ga tc�ra� Installer's Name,Address,and Tel.No. ,R Designers Name,Address and Tel.No. �G s •/�%t( Type of Building: DwellingNo.of Bedrooms 13 Lot Size A 66 e sit. Garbage Grinder; Other Type of Building No.of Persons Showers( ) Cafeteria( ) r Other Fixtures Design Flow 33Q gallons per day. Calculated daily flow gallons. Plan Date k)c C Ot- G 3 Number of sheets `Revision Date Title Size of Septic Tank CA1, xi 7,;t6 Type of S.A.S. 4yS��f�N XiGvc�� V, d Description of Soil `/�/ ,Srj,���.. �o�l�l4..,./,e00%s 3/ /e' /.�'�= .Je/�'�J•-1iYj ,h� �",/���- !/t^�� Ck'ri�c •Y r}1 ror�.� 5fan.� - .. Nature of Repairs or Alterations(Answer when applicable) �4 a"t ;j S-Q0 cd l�r,t,�•c�( � cv. l� f- J ti s Date last inspected: Agreement: The undersigned'agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by this Bo d of H Signed Date -S� 3-G.3 Application Approved by -S' Date 9 .3-G.3 Application Disapproved for the following reasons .6 Permit No. 200 — 2- Date Issued ` 1 03 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(P, T Upgraded( ) Abandoned( )by S F1C t at (,_4 Croo�zu CPivaa, - M.�c ,ion, (111(1, has been constructed in accordance with the provisions o Title 5 and the for Disposal System Construction Pe t No. 2=3 y2-7 dated 9"3 03 Installer y r / /(i C c//. Designer k_j \S 5 t C, The issuance of thi pe it shall not be construed as a guarantee that the system g . d. Date L Inspector .00 No. ---------------------=—=--Fee J�/ -'-------•-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mwigozal 6potem Construction Permit Permission is hereby granted to Construct( )Repair( kf Upgrade( )Abandon( ) System located at C/va<<3 ���l��,� - l7�� �;,,, /`/,'11 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe es Date: .3`O 3 Approved by TOWNDF BARNSTABLE SEWAGE#JDO3"'�/oZ I LOCATION 020O�O % r ASSESSOR'S MAP & LOT - VILLAGE INSTALLER'S NAME&PHONE NO. ff</�C�` SEPTIC TANK CAPACITY l/0acu 6"9f (size) l3 t LEACHING FACILITYpe) ,)as -4-Sd"t2o : NO.OF BEDROOMS BUILDER OR OWNER rLs PERMITDATE: G�►T_3—O 3 COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table tp the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) exist Edge of Wetland and Leaching Facility(If any Feet within 300 feet of leaching facility) Furnished by. ....-_._.-.... I j �r o -'6� 2, x l o R q-� +-e-r S i S k �A- T a s r 13; e p 7V ✓:;- ra :: ff>° s� ���� �r a 2., ���,'£B��Y�PZ -�'.b,�!'4�m•�� Yqa �.h 1A�7 ��.�i"�4z Ps 2 - Z-x C ` SAS `v`lr�l l s Gkc � 0 CAP� ��CJ �('S art�i �v� g JZ f cl s VA -Fouv\ jckA'kon 0 VA °fin/ �- i �'"� CAP_j C S � � 1n G l e—S V f -�(-om 14oust Vvy w k c��S tVVI � 3 A M Y + gam amr� � 5 s� w a Ago, >/1 � r15�r�'t h��h.�u v r�5 � 1{ y,�a�C�s��d��S>�d-tC yn 1 i� ^� .� � [�u: f�•k�l �'� +f. 4 `� �� n r-k , � fir "y4 y7.,.f�° � `at�"''i"�}y � y�fi.,vsrv4�t�vklb�" 4��y rc�ri�sv• ,y,'�ttk., �•a f� p-_ 'y4' f",y;hc i n�y r apt- p' ' � ��,i„;�a MT:,`�a Y 4 �¢ �.'�� 'w1•.Y.f �1n� tsar.vt �,�}y��E. �Sv��s'"y€' 'Vii 7 I ROOT A— - 1 33-4" N k 0) a 1"00'OL x HE t n O b °f /41.86 dn 3'-3"��6'-9" 12'-0^ yX 0"x 6'--8"CO OD N �O -21 ki O Cl) N 13'-8" N a � a k (V °i 1 8c 12'-4" co w _ b x 8"K 6'-6" co I co i 0) N 9 J! J CO T-1" 6'-11" 6'-0"f—6,4" 3'-0"x 4'-0" e- to 8'-0"x 6'-8"Arch a 0 k O - � N AdJt+"\ VA O� � W �. o k k Q w C� 2 '-0" u? N O 4'-5" —3'-3- f T-0" 3'-9 4'-1" 2'-6' 3 0"x 6' "x 6' "Fr 3'-O"x 3'2" 3'-0"x 3'-2" 3'-0"x 3'-2" 1 - 10 No. � ' �. ee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppYicatfon for 33i5po5ar *p!tem Construction Vertu Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 52 Crooked Cart Way Mrs Davis Marstons Mills Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinson Septic P.O. Box 1089 Genterville Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( np Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install 4 high c a p c i t y infiltrators and d—box Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of theFnvironmental C and t to place the in operation until a Certifi- cate of Compliance has been issued by this Bo of Hea Signed D t Application Approved by Application Disapproved for the following reasons Permit No. Date Issued - p'+v. ....-y:..:p.� Lr ,,.,i yr ....,.,,... ..,a..-.t•+.:s+o+�C.3v.ra>:.- ;�;.... ,:...:a:r::.,., {�;, ;q'� .: .N:e. .� ,--. } .•: No.�`y v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Dizpo ` p5tem Construction Permit Application is hereby made for a Permit to Construct( )o RepairLk), an On- 'te;SewagwDispos 1 System tYM Location Addressor Lot No. Name,Address and Tel. 62 Crooked Cart Way '` �s Davis Marstons Mills f Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No, W.E. Robinson Septic P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( njc Other Type of Building ' No.of Persons Showers 1,7) C7a i�( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Na u fRe ai s orAlterat'ons(Answer when applicable) install 4 high cap.city in�� lt�ra�ors anc d-box Date last inspected: Agreement: ? - - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Fnvironmental C and 61 to place the tem in operation until a Certifi- cate of Compliance has been issued by t is Bo Hof Hea . �` / Signed D tom` Application Approved by Application Disapproved for the following reasons. Permit No. ^` fS Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired7replaced(x )on by W.E. Robinson Septic . for Mrs Davis as 62 Crooked Cart Way has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set,forth below. - �� 40.00 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=i!5po!5a1 *pgtem Construction Permit Permission is hereby granted to W.E. Robinson Septic Service to construct( )repair(x )an On-site Sewage System located at 67 rranked _Cart blay N and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: 2 rr0 1 n Approved by t CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS'I1UC110N I'ERMI'I' (IVI'['IIOU'I' DESIGNEll PLANS) 1, hereby certify that the application for disposal works construction permit signed by me dated 0/4 , concerning the -® '-P� ��� meets all of the property located at � o� C 4 �G � � following criteria: • There are no wetlands within 300 feet of the proposed septic system • There arc no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: 7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed Installer posesses n certified plot plan, this plan should be submitted]. i I \ 4 { Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection CCIII William F.weld MAR 6 1 996 Goamor sxrodt.y,oEA d, � David B.Struhs �F r Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM k t-,% CA f !dA y PART A CERTIFICATION Property Address: Address of Owner: Date of Inspection: `°� 7` w (if different) Name of Inspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT 77'�77 I certify that I have personally inspected the sewage dispos�l sPsTerh t this address and that the information reported below is true, accurate r and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _V Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails I Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYST PASSES: 7I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] S TEM CONDITIONALLY PASSES: ne or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, as inspection. Indicate y s, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why riot) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revisf 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)SW1049 • Telephone(611)292-55M 40 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (p� Cr/'OC1 k ee c -T (,t 4 y Ina/`.5wi Owner: �7rc vt t:. I�i9U�`S Date of Inspection: B]SYST CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the p lic health, safety and the environment. 1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER W ICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT HE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTE FAILS: I h e determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the fai ure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,/ CERTIFICATION (continued) / Property Address: to� �re d/� e D Ca-,- 7— Owner: cJ"-rr �fjVki Date of Inspection:,, .7 i 1 D)SYSTE FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE YSTEM FAILS: Th following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: /7 Date of Inspection: � r)— 2, Check if the following have been done: dumping information was requested of the owner, occupant, and Board of Health. =tIN/one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �7Th. ilt plans have been obtained and examined. Note if they are not available with N/A. 'facility or dwelling was inspected for signs of sewage back-up. _ ac ry g P g he system does not receive non-sanitary or industrial waste flow 4Zfhe site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. "'e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. Vhe facility o��ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: rd ���� C� r 01,91V i Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: ?® stallons Number of bedrooms: Number of current residents: 1 Garbage grinder(yes or no):—ILI Laundry connected to system (yes or no):,,V-- Seasonal use (yes or no):4/ J Water meter readings, if available: 9 0 C Y,a -� Last date of occupancy: COMM RCIAUINDUSTRIAL: Type of stablishment: Design fl w: allons/day Grease tr p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanit ry waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available: Last dat of occupancy: OTHER (Describe) Last dat of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)-,Z4= If yes, volume pumped. 10 6---g s Reason for pumping: L- TYPE O SYSTEM 1 Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: �� —�Q !� I✓ b 1 Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Gi� C'/'�® ,�1�c' C,4 1�7- IJ/9-/ M,61-S twj �✓/,�/LS Owner: '-Tvc rt 'f— vp�l i//'S Date of Inspection: 'Z' ^;L ` SEPTIC TANK:_ (locate on site plan) Depth below grade: � t Material of construction: _concrete _metal _FRP—other(explain) / Dimensions: "r Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:3 �b Scum thickness: / ' ' , Distance from top of scum to top of outlet tee or baffle: 7 , Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) CA: , A- Id 141 TA--Z :F-7 ot- s �oP GREA TRAP:_ (locate site plan) Depth be w grade: Material construction: _concrete _metal _FRP—other(explain) Dimensi ns: Scum t ickness: Dista a from top of scum to top of outlet tee or baffle: Distance rom bottom of 5rurr t^ hOttOm of OLMet tee or baffie: Comments. (recommen ation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, a idence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �0', Y 4 lJ k-p—e. ` Owner: Date of Inspection: �' � Ul�", ml19/c� TIGHT HOLDING TANK:_ (locate on ite plan) Depth belo grade: Material of co struction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: allons Design flow: allons/day Alarm leve Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distributiur, is equal, evidence of solids carry-over, evidence of leakage into or out of box, etc.) PUMP CH MBER:_ (locate on si plan) Pumps in wor ing order:(yes or no) Comments: (note conditio of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION (continued) Property Address: (D 01-ee,,Iet J7 , Ca r T VU,, y m6 r0a i Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):v (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type ., U leaching pits, number._ � � G e�� �� S�s 7 6 *L � C leaching chambers, number: / leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of v getation,etc.) tic/Z: 0 A., n«0Acf 7-0 )3 l� �, v Y CESSPOOLS: _,Z'— (locate on site plan) Number and configuration: P/ Depth-top of liquid to inlet invert: Depth of solids layer: Depth of Scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Commen : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Mate s of construction: Dimensions: Depth solids: Commen : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �1J� �"v e k-e— Owner: -�- Date of Inspection: rff� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' l �6 U� / J I DEPTH TO GROUNDWATER Depth to groundwater: S-' feet method of determination or approximation: d YS R a 6 f�! (revised 8/15/95) 9 TOWN OF BARNSTABLE f 0 /1 LOCATION6-- �h o C /�c C`O"I t y� i SEWAGE # 7 Y VILLAGE lam ?- i/Y*" ASSESSOR'S MAP&LOT0 6 5t G03 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 16>0 U LEACHING FAciLrrY: (type) (size) t 2 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: �. ��L COMPLIANCE DATE: —A `7- 9 � Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) a�" Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by / F ��a � � .r l' /� `� d ��. �� P /� _� / 33 . � ; ��� � ,� / �' �� �� -� - SOILS TEST" RE��ULTS F/N. FL o oR i/L /0 9.8Z SE WA 6. SYSTEM PRO F/G E 0" 'TYR 5/2 S.9NdY GoAM Ao /It„ W/RdOTs _ k6 'MW- IAIV- MAx- ,. n/ � 7•s yR %g LOAM9_ Ml MAx- 36"MAX. . 9"M!{J•1Z-" M/til. /A/NER ME,QSUReF /n/v- 36" MAX , " � M5cH-4D PVC SCH. 4p Pv �P Ll�90 cAPAC/Ty /10S• 82 2.,COVE12 DF �.¢ — �2 STONE 3�• [_Iqu/D L�cVELC P E 4 sc"..¢o PVG 7a /NV• � I4" INV• /Nv y 3 3 ti' S YR �/ LOAM Ci /oG•99 /06.79 lob• 5�- /oG /¢ /os.97 /4'-//i• o o a, a a a I4 -i/t 4- 6''g� or- ...•. .;:.,r STONE �2� Soo GAL.-'CNAM$E{:S STONE0 z' OFF• DEPTH 72„ ��. /02 ./ C2(JS N E D o`o e v c —7 C7 co Ci � r r o o C d ' r,.i . .: , . . STONE EL /�3• $Z a o0 00 -ZO OAD/NG G9PAC/ 6-0�w VERY CXISTING 1000 C- PRECAS7- STEPT/C TAWk �{ ----- 4'/b" 4' 6RAVS-4Y 12' 10 � /o YR 1�3 MEN/u/y C z 6 -72 So/[-5 A85o ;PT/O/�l SYSTEM SAND EL• 97•/0 goTTOM of "TE5T PIT NoTE ; CoN7PAC-r0R SNAIL .REMOVE AGL. 41A/sU17ABL.E MATERIAL /32''.' Et. 97-/ WIT141AJ -TNE S. A . S. ANb A 5 ' LATERAL- ExTENslon/ T/ls,eEOF GROUN�L�/f1TE�C' NdT �ivCourVT��'�� DOWM 70 THE SANS LAYER AT APPROX. EL. 102.1 AN,b REPLACE WITH CL.EAIV GRANULAR MA'TERW ,Jlv ACCORDANCE W17-N SO/GS T2sT 0472-: = 8-/3- 6 310 CMR I S• 2 55 (3,- E,YGAVA TOR 1 ,B.QIJGE Mc ALA/STAR SD/L S EVAL L147OR : �/ON�C/ .h dYG AE/?C. RATE < 2 M/N /NC.S/ 3 _ WASHED STONE G e 4• SD<LS TEXTURA� C'L1�55' : ONE QcvcH M.9�eK TvP SP/w�LF vn/ 'L TVJo Soot- �/2� 11y-bX ,V7-- 3� .p0 IZ, 83 4' LEACH C HAMBE2S 4' WA5HED STONE ¢ 5-CH.40 P v c VEN T ,5-VRF4CE / PE)z 310 CMR 15. Z41 LOCAT/ON To BE PLAN VIEW OF S.A. 5, MqP GS PARCEL .3 . io8•t8 � � Cr/AMBEJes� SEWAGE SYSTEM 1)E51GN CALC[3LA716N5 h•( X _ 3 5E.)k00MS X l/0 GPb 33C) GP.d /08.53 T i PRoP�sCD �C 2- FEQUIKED {NF1LT�2AT/ON AREA = A p, p/( 330 — O.7¢ = 4-Q-G S.F, D L-/2. 3 ' US& 7W0 2 500 G, PRECAST LEAcN CHAMBECS y � s soil Is7 X � O ReMov.�L 006 WITH 4 OF WASHED -STONE ARDUND. °�� , pr/K G F pCvs 0 q` x N 4, INFILTRATION h AEA PROVI S ION = 1o8 e/1,` /08• �� / N� ��' X p $OTTOM = 12. 8 3 x 25' = 3 Z O S•F R.9cE � 1 +(�Y �jv SIDES = (25.CC-t 50)x 2 TOTAL- AREA = 4 7✓ S,F- w h m J� x v ��- /O g• z 9 X D x LOCUS"A-14p SCALE= /0 7, 3 ti Pf�.eCEL /t/O- '3 -Sr WA GE S"y,STEM LJPGRA D G- /o L A A/ 41 >.. �, i o� .lQNN Cf/AKLES _ANL MEL/SSA C/POS,B y Lfi r P. G 1Va asses y CW-57/N6 3 //V G WILUAM 1mW?AAN SURE 40.xwI to Z CA'OOKE,D CART>"AY -s �' on at BAR�STABL E 5 m 4 ,S . ZOGs3 `� e EP T /3 W � W � Z I �3 SGAGE=/"= 3D" AUGUST Z9, ZDa3 N _ I _ scAtt /N F.EE7 c/.,A OYL Cr ATSO CM T,r S S08- Sd 3- /9 9¢ P p. Box 595 W,�,gcMo uTf/, MA. OZ S 7,4 -